2023-08-12 COI GL AL WC.pdf

SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE

THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN

ACCORDANCE WITH THE POLICY PROVISIONS.

INSURER(S) AFFORDING COVERAGE

INSURER F :

INSURER E :

INSURER D :

INSURER C :

INSURER B :

INSURER A :

NAIC #

NAME:

CONTACT

(A/C, No):

FAX

E-MAIL

ADDRESS:

PRODUCER

(A/C, No, Ext):

PHONE

INSURED

REVISION NUMBER:CERTIFICATE NUMBER:COVERAGES

IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed.

If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).

THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED

REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.

OTHER:

(Per accident)

(Ea accident)

N / A

SUBR

WVD

ADDL

INSD

THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.

$PROPERTY DAMAGE

BODILY INJURY (Per accident)

BODILY INJURY (Per person)

COMBINED SINGLE LIMIT

AUTOS ONLY

AUTOSAUTOS ONLY

NON-OWNED

SCHEDULEDOWNED

ANY AUTO

AUTOMOBILE LIABILITY

Y / N

WORKERS COMPENSATION

AND EMPLOYERS' LIABILITY

OFFICER/MEMBER EXCLUDED?

(Mandatory in NH)

DESCRIPTION OF OPERATIONS below If yes, describe under

ANY PROPRIETOR/PARTNER/EXECUTIVE

E.L. DISEASE - POLICY LIMIT

E.L. DISEASE - EA EMPLOYEE

E.L. EACH ACCIDENT

ER

OTH-

STATUTE

PER

LIMITS(MM/DD/YYYY)

POLICY EXP

(MM/DD/YYYY)

POLICY EFF

POLICY NUMBERTYPE OF INSURANCELTR

INSR

DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)

EXCESS LIAB

UMBRELLA LIAB $EACH OCCURRENCE

$AGGREGATE

OCCUR

CLAIMS-MADE

DED RETENTION $

$PRODUCTS - COMP/OP AGG

$GENERAL AGGREGATE

$PERSONAL & ADV INJURY

$MED EXP (Any one person)

$EACH OCCURRENCE

DAMAGE TO RENTED

$PREMISES (Ea occurrence)

COMMERCIAL GENERAL LIABILITY

CLAIMS-MADE OCCUR

GEN'L AGGREGATE LIMIT APPLIES PER:

POLICY

PRO-

JECT LOC

CERTIFICATE OF LIABILITY INSURANCE

DATE (MM/DD/YYYY)

CANCELLATION

AUTHORIZED REPRESENTATIVE

ACORD 25 (2016/03)

© 1988-2015 ACORD CORPORATION. All rights reserved.

CERTIFICATE HOLDER

The ACORD name and logo are registered marks of ACORD

HIRED

AUTOS ONLY

Phoenix, AZ, 85009

1324 N. 22nd Ave.

State of Arizona / ADOT

The State of Arizona or ADOT is named additional insured including ongoing and completed operations for general liability and commercial auto. Coverage is considered primary and non-contributory over any other insurance. A waiver of subrogation applies in favor of the certificate holder for general liability and commercial auto.

1,000,000

1,000,000

1,000,000

03/29/20403/29/2023006284780YA

1,000,000

08/12/202308/12/2022648906879YY

A

2,000,000

2,000,000

1,000,000

15,000

300,000

1,000,000

08/12/202308/12/2022006010897YY

A

Pekin Insurnace

86327AZDewey

PO BOX 1513

Az Strongbox, LLC kevin@kortsenins.com

928-527-1918928-527-1914

Kevin Kortsen

86001AZFlagstaff

1016 W University Ave. Ste 102

Kortsen & Associates Insurance

3/30/2023

ACCEPTED

ADOT Risk Management

006010897

The State of Arizona or ADOT

POLICY NUMBER: COMMERCIAL GENERAL LIABILITY

CG 24 04 10 93

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

CG 24 04 10 93 Copyright, Insurance Services Office, Inc., 1992

WAIVER OF TRANSFER OF RIGHTS OF RECOVERY

AGAINST OTHERS TO US

This endorsement modifies insurance provided under the following:

COMMERCIAL GENERAL LIABILITY COVERAGE PART

SCHEDULE

Name of Person or Organization:

(If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.)

The TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US Condition (Section IV - COMMERCIAL GENERAL LIABILITY CONDITIONS) is amended by the addition of the following:

We waive any right of recovery we may have against the person or organization shown in the Schedule above because of payments we make for injury or damage arising out of your ongoing operations or ''your work'' done under a contract with that person or organization and included in the ''products-completed operations hazard'' This waiver applies only to the person or organization shown in the Schedule above.

648906879

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

BPM 3148 05 15 Includes copyrighted material of ISO Properties, Inc. with its permission.

PRIMARY/NON-CONTRIBUTORY ADDITIONAL

INSURED

This endorsement modifies insurance provided under the following:

BUSINESSOWNERS COVERAGE FORM

The following is added to Paragraph H. Other Insurance of Section III - Common Policy Conditions

Primary Additional Insured – If a written contract or agreement or permit requires this insurance to be primary for any person or organization with whom you agree to include in paragraph C. Who Is An Insured of Section II – Liability as additional insured, this Other Insurance provision is applicable. This insurance is primary. This insurance is also non-contributory which means we will not seek contribution from other insurance available to the person or organization with whom you agree to include in Who Is An Insured.

COMMERC TOIAL AU

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

BLANKET ADDITIONAL INSURED

This endorsement i ies insurance pro ided under t folmod f v he lowing:

BUSINESS O C AGE ORMAUT OVER F

MOT ARRIER C GE ORMOR C OVERA F

TRUCKERS C GE ORMOVERA F

W t respect to co rage pro ided by this endorse- a written contract or agreement that is signed andi h ve v ment the pro isions o the Co erage For apply executed by you before the "bodily injur " or "property, v f v m y unless modi ied by damage" occurs and that is in ef t during the polf the endorsement. fec icy period is an "insured" for L li Co erage, but onlyiabi ty vThe fol is added to thelowing Section II L lityiabi for da ages to which this insurance applies and onlymCoverage, A.1. Who Is An I dParagraph Pro-nsure to the e that person or organization qual f asxtent i ies v ion:is an "insured" under the Who Is An Insured provision contained in ionSect II.Any person or organization that you are required to include as addit insured on the Co erage For inional v m

CA T4 37 08 08 © 2008 The Travelers Companies, Inc. Page 1 of 1